Justification for Whistleblower Mediation State, Local, and Tribal Government Employer Survey

Request for Approval under the “DOL Departmental Generic Clearance for
the Collection of Routine Customer Feedback”
(OMB Control Number: 1225-0088)
TITLE OF INFORMATION COLLECTION:
Whistleblower Alternative Dispute Resolution Program Questionnaire
PURPOSE:
U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) intends to
conduct a customer satisfaction Questionnaire as part of OSHA’s Whistleblower Alternative
Dispute Resolution Program (“ADR Program”). The questionnaire is one aspect of a pilot
program OSHA is implementing to administer mediation services for its whistleblower
complaint activities, which arise out of complaints filed under the whistleblower provisions of
the 22 statutes administered by OSHA’s whistleblower program. The ADR Program is designed
to assist employers and employees in resolving their disputes (whistleblower complaints) in a
cooperative and voluntary manner. In this pilot, the Federal Mediation and Conciliation Services
(FMCS) is serving as the neutral third party mediator.
The Whistleblower Alternative Dispute Resolution Program Questionnaire (“questionnaire”) is
designed to determine the satisfaction level of employers who opt to participate in the mediation
services being offered through the ADR Program. Specifically, with this questionnaire, OSHA is
looking to see whether respondents are satisfied with the mediation process, the information
OSHA provides throughout the mediation process, and the overall procedures of the pilot
program. In addition, OSHA will use this questionnaire to determine what areas of the pilot
program need adjustment to better satisfy the employers that opt to engage in mediation through
the ADR Program.

DESCRIPTION OF RESPONDENTS:
Questionnaire respondents will include public sector employers who have had whistleblower
complaints filed against them by an employee or employees, and have voluntarily opted to
participate in the ADR Program. The respondents will be from state, local, or tribal
governments. Respondents will take the questionnaire online after mediation services have been
rendered. They will be provided information regarding the questionnaire by their respective
Regional ADR Coordinator via email after the mediation.

TYPE OF COLLECTION: (Check one)
[ ] Customer Comment Card/Complaint Form
[ ] Usability Testing (e.g., Website or Software
[ ] Focus Group

[X] Customer Satisfaction Survey
[ ] Small Discussion Group
[ ] Other: ______________________

CERTIFICATION:

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I certify the following to be true:
1. The collection is voluntary.
2. The collection is low-burden for respondents and low-cost for the Federal Government.
3. The collection is non-controversial and does not raise issues of concern to other federal
agencies.
4. The results are not intended to be disseminated to the public.
5. Information gathered will not be used for the purpose of substantially informing influential
policy decisions.
6. The collection is targeted to the solicitation of opinions from respondents who have
experience with the program or may have experience with the program in the future.
Name: Laura Seeman, Chief, Division of Operations, Office of the Whistleblower Protection
Program
To assist review, please provide answers to the following question:
Personally Identifiable Information:
1. Is personally identifiable information (PII) collected? [ ] Yes [X] No
2. If Yes, is the information that will be collected included in records that are subject to the
Privacy Act of 1974? [ ] Yes [ ] No NA
3. If Applicable, has a System or Records Notice been published? [ ] Yes [ ] No NA
Gifts or Payments:
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to
participants? [ ] Yes [ X] No

BURDEN HOURS
Category of Respondent

Burden

State, local, or tribal governments

No. of
Participation
Respondents Time
30
30 minutes

Totals

30

15
hours

30 minutes

15

OSHA seeks approval to send this customer feedback questionnaire to parties who elect and are
selected to participate in 30 pilot mediations. In most cases, a mediation will involve one
employee and one employer from either the private, Federal government or State, local or tribal
government sectors. Thus, the Agency is submitting separate generic clearance requests for four
categories: 1) individuals/workers; 2) private sector employers; 3) State, local or tribal
government employers, and 4) Federal government employers. The Agency has no way to
determine how many of the 30 mediations will involve the different categories of
employers. While the Agency expects that most mediations will involve private sector
employers only, the Agency is accounting for the possibility that some mediations could involve
either a Federal or State/local/tribal government employer. Thus, the Agency intentionally
included overestimations of 30 responses for the Federal and State/local/tribal government

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employer categories, respectively. It is possible that multiple private sector employers may
participate in one mediation; therefore, in the request for clearance of collection of questionnaire
feedback from private sector employers, the Agency has included additional responses, burden
hours and cost to account for this possibility.
FEDERAL COST:
OSHA estimates that a Program Analyst (GS-09, step 1), with an hourly wage rate of $24.74,1
will spend about 8 hours developing the questionnaire, and spends another hour posting the
questionnaire to Survey Monkey. In addition, a Program Analyst (GS-11, step 1), with an hourly
wage of $29.93,2 will perform data analysis related to the questionnaire for approximately 8
hours. Therefore, the total annual cost of these paperwork requirements to the Federal
government is:
Questionnaire Development
8 hours of GS-9, Step 1 time x $24.74/hour = $198
Post to Survey Monkey
1 hour of GS-9, Step 1 time x $24.74/hour = $25
The Survey Monkey Basic Account is free of charge.
Data Analysis
8 hours of GS-11, Step 1 time x $29.93/hour = $239
Total Cost to the Federal Government = $462

If you are conducting a focus group, survey, or plan to employ statistical methods, please
provide answers to the following questions:
The selection of your targeted respondents
1. Do you have a customer list or something similar that defines the universe of potential
respondents and do you have a sampling plan for selecting from this universe?
NA
[ ] Yes [ ] No

1 Source: U.S. Office of Personnel Management, General Schedule and Locality Tables, Salary
Table 2012-DCB, http://www.opm.gov/oca/12tables/html/dcb_h.asp .
2 Source: U.S. Office of Personnel Management, General Schedule and Locality Tables, Salary
Table 2012-DCB, http://www.opm.gov/oca/12tables/html/dcb_h.asp .

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If the answer is yes, please provide a description of both below (or attach the sampling plan)? If
the answer is no, please provide a description of how you plan to identify your potential group of
respondents and how you will select them?
NA

Administration of the Instrument
1. How will you collect the information? (Check all that apply)
[X] Web-based or other forms of Social Media
[ ] Telephone
[ ] In-person
[ ] Mail
[ ] Other, Explain
2. Will interviewers or facilitators be used? [ ] Yes [X] No
Please make sure that all instruments, instructions, and scripts are submitted with the
request.

Instructions for completing Request for Approval under the “Generic
Clearance for the Collection of Routine Customer Feedback”
TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the
subject of the request. (e.g. Comment card for soliciting feedback on xxxx)
PURPOSE: Provide a brief description of the purpose of this collection and how it will be used.
If this is part of a larger study or effort, please include this in your explanation.
DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or
groups for this collection of information. These groups must have experience with the program.
TYPE OF COLLECTION: Check one box. If you are requesting approval of other
instruments under the generic, you must complete a form for each instrument.
CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the
collection will be returned as improperly submitted or it will be disapproved.
Personally Identifiable Information: Provide answers to the questions.
Gifts or Payments: If you answer yes to the question, please describe the incentive and provide
a justification for the amount.
BURDEN HOURS:
Category of Respondents: Identify who you expect the respondents to be in terms of the
following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal
governments; or (4) Federal Government. Only one type of respondent can be selected.

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No. of Respondents: Provide an estimate of the Number of respondents.
Participation Time: Provide an estimate of the amount of time required for a respondent to
participate (e.g. fill out a survey or participate in a focus group)
Burden: Provide the Annual burden hours: Multiply the Number of responses and the
participation time and divide by 60.
FEDERAL COST: Provide an estimate of the annual cost to the Federal government.
If you are conducting a focus group, survey, or plan to employ statistical methods, please
provide answers to the following questions:
The selection of your targeted respondents. Please provide a description of how you plan to
identify your potential group of respondents and how you will select them. If the answer is yes,
to the first question, you may provide the sampling plan in an attachment.
Administration of the Instrument: Identify how the information will be collected. More than
one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or
facilitators (e.g., for focus groups) used.
Please make sure that all instruments, instructions, and scripts are submitted with the
request.

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